Antimicrobial Resistance

Context (PIB): The Government announces India’s first indigenous antibiotic, Nafithromycin, to tackle Antimicrobial Resistance (AMR).

It is a collaborative effort supported by the Biotechnology Industry Research Assistance Council (BIRAC) under the Department of Biotechnology (DBT) and under the Biotechnology Industry Partnership Program (BIPP) brought to market by Wockhardt under the trade name Miqnaf.
It is specifically developed to treat Community-Acquired Bacterial Pneumonia (CABP), a severe condition caused by drug-resistant bacteria.
CABP disproportionately affects vulnerable groups such as children, the elderly, and immune-compromised individuals, including patients with diabetes and cancer.

What is Antimicrobial Resistance (AMR)?

Antimicrobials include antibiotics, antiviral, antifungal & anti-parasitic medication.
The WHO defines antimicrobial resistance (antibiotic, antiviral, antimalarial resistance) as a microorganism’s resistance to an antimicrobial drug that was once able to treat an infection by that microorganism.
E.g., In Multi-Drug Resistant TB (MDR-TB), the TB bacteria are resistant to two of the most important TB drugs, isoniazid (INH) and rifampicin (RMP).

Causative Factors for Antimicrobial Resistance

Antimicrobial resistance occurs when bacteria, viruses, fungi & parasites change over time & no longer respond to medicines.
They become Superbugs and become resistant to the drugs that should usually destroy them.
Micro-organisms can develop resistance mainly in two ways:
- Intrinsic resistance: Ability of an organism to resist a class of antimicrobial agents.
- Acquired resistance: Micro-organisms acquiring the gene coding (genetic mutation) for resistance.
Intrinsic Antimicrobial resistance (AMR) occurs naturally over time, usually through genetic changes.
Acquired resistance is more common than intrinsic resistance.

Causes Behind Acquired Antimicrobial Resistance

Overuse, misuse, and improper use (e.g., taking antibiotics to treat viral diseases!) of antimicrobials.
Greater access to over-the-counter antibiotic drugs in developing countries.
Using broad-spectrum antibiotics over narrow-spectrum antibiotics (targeting specific microbes only).
Dumping of inadequately treated effluents from the pharmaceutical industry.
Antibiotic use in livestock feed at low doses for growth promotion is industrialized countries.
Poor sanitation and hygiene that forces the extended use of antimicrobials.

World’s rivers loaded with antibiotics waste

The concentrations of major antibiotics like Ciprofloxacin (treatment for intestinal and urinary tract infections) and metronidazole in water bodies were several times above the limit in many parts of the world.

Why are Antibiotics effective against Bacterial Infections but not Viral Infections?

Taxonomically, all bacteria are closely related to each other than to viruses & vice versa.
This means that many important life processes are similar in the bacteria group but are not shared with the virus group.
As a result, drugs that block one of these life processes in one member of the group is likely to be effective against many other members of the group.
But the same drug will not work against a microbe belonging to a different group.
As an example, let us take antibiotics. They commonly block biochemical pathways important for bacteria.
Many bacteria, for example, make a cell-wall to protect themselves.
The antibiotic penicillin blocks the bacterial processes that build the cell wall.
As a result, the growing bacteria become unable to make cell-walls & die easily.
Human cells don’t make a cell-wall anyway, so penicillin cannot have such an effect on us.

mechanisms of antibiotics

Similarly, many antibiotics work against many species of bacteria rather than simply working against one group.
But viruses do not use these pathways at all, & that is the reason why antibiotics do not work against viral infections.
If we have a common cold, taking antibiotics does not reduce the severity or the duration of the disease.
However, if we also get a bacterial infection along with the viral cold, taking antibiotics will help.
Even then, the antibiotic will work only against the bacterial part of the infection, not the viral infection.

Why is it harder to make antivirals compared to antibiotics?

Unlike bacteria, viruses have few biochemical mechanisms of their own.
This means that there are relatively few virus-specific targets to aim at.
Despite this limitation, there are now effective anti-viral drugs, for example, the drugs that keep HIV infection under control.

Concerns Raised Due to Antimicrobial Resistance

As a result of drug resistance, it has become increasingly difficult or impossible to treat some diseases.
Treating resistant microbes require alternative or higher doses of medication (expensive + toxic).
In 2016, upto 4,90,000 people developed multi-drug-resistant TB globally.
Drug resistance is starting to complicate the fight against HIV and malaria.
Organ transplantation, chemotherapy & surgeries would be compromised without effective antimicrobials.
Medical procedures, such as surgery have become riskier.
Antimicrobial resistance increases the cost of health care with lengthier stays in hospitals, additional tests & use of more expensive drugs.
It can ultimately lead to Antibiotic Apocalypse – A future without antibiotics, with bacteria becoming completely resistant to treatment & when common infections & minor injuries could once again kill.

Steps taken Globally to fight Antimicrobial Resistance

Global Action Plan on Antimicrobial Resistance (GAP)

Globally, countries committed to the framework set out in the Global Action Plan (GAP) 2015 on AMR during the 2015 World Health Assembly.
t mandated nations to develop & implement national action plans to tackle microbial resistance.

Tripartite Joint Secretariat on Antimicrobial Resistance

A tripartite joint secretariat (FAO, World Organisation for Animal Health (OIE) & WHO) is established in 2016.
It aims to drive multi-stakeholder engagement in AMR.

World Antimicrobial Awareness Week (WAAW)

Held annually since 2015.
It is a global campaign that aims to raise awareness of antimicrobial resistance worldwide.

The Global Antimicrobial Resistance & Use Surveillance System (GLASS)

It was launched by WHO in 2015 to continue fill knowledge gaps & to inform strategies at all levels.
It is conceived to progressively incorporate data from surveillance of AMR in humans, medicines, food chain & in the environment.

Global Research & Development priority setting for AMR

In 2017, to guide research & development into new antimicrobials, diagnostics & vaccines, WHO developed the WHO priority pathogens list.
It will be updated in 2022.

Global Antibiotic Research & Development Partnership (GARDP)

A joint initiative of WHO & the Drugs for Neglected Diseases Initiative (DNDi).
The partnership aims to develop & deliver 5 new treatments that target drug-resistant bacteria identified by WHO as posing the greatest threat by 2025.

Steps Taken by India to Fight Antimicrobial Resistance

India formed the National Action Plan to combat Antimicrobial Resistance.
The National Health Policy 2017 highlights the problem of antimicrobial resistance & calls for effective action to address it.
Since 2014 a separate Schedule H-1 has been incorporated in Drug & Cosmetic rules to regulate the sale of antimicrobials in the country.
Health Ministry initiated Red Line Campaign:
- It urged people not to use the medicines marked with a red vertical line without prescription.
The Food Safety & Standards Authority of India (FSSAI) banned the use of antibiotics & several pharmacologically active substances in fisheries.

2019: Colistin banned in animal food industry

The Ministry of Health and Family Welfare has prohibited the manufacture, sale and distribution of colistin and its formulations for food-producing animals, poultry, aqua farming and animal feed supplements.
The move is a “massive victory” for the movement against anti-microbial resistance.

National Action Plan – India

National Action Plan to combat Antimicrobial Resistance is on the lines with World Health Organization’s Global Action Plan (GAP) for AMR.
The plan highlights the need for tackling AMR across multiple sectors such as human health, animal husbandry, agriculture & environment in consideration of the “One-Health” approach.

Priority Areas

Education & Training

Revision of curriculum for professionals in animal, agriculture & environment sector with focus on AMR.

Surveillance

Conducting national-level surveillance of antibiotic residues in food from animals & in environment.

Infection Prevention & Control

Restricting antibiotics in animal feed, & regulating their import, direct distribution & online marketing.
Eliminating use of critically important antimicrobials for humans in food animals.
Ensuring prescription sale of antibiotics & appropriate labeling of food from animals produced with or without routine use of antibiotics.

Environment

Strengthening of necessary laws & regulations, environment risk assessment; extended producer responsibility for expired/unused antibiotics.

Suggestions to Improve India’s fight against AMR

Provide a supportive environment for startups: E.g. Pfizer COVID-19 vaccine was developed by the relatively small German startup BioNTech.
Development of advanced rapid diagnostics: Prompt and precise detection of infections is essential for curbing the spread of resistant microbes.
Cultivating indigenous phage therapies: India imports high-quality phages from Eastern Europe.
We need to channel our efforts into developing new, innovative vaccines such as therapeutic vaccines. These are designed to prevent the recurrence of infections.
Need to prioritise infection control strategies.
- A vast majority of our hospitals lack the requisite policies, committees, and expertise for effectively preventing drug-resistant infection transmission to patients.
Prescribe antibiotics only when needed and in the right doses. Overusing and misusing antibiotics in humans, livestock, and crops are the main reasons for antimicrobial resistance.